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Based on facility policy, interviews with facility staff, Emergency Department (ED) physician and the local Ambulance Service Director, review of the ED registration log, and review of the ambulance run report it was determined the facility failed to provide a Medical Screening Examination (MSE) and stabilizing treatment for a patient involved in a motor vehicle accident that arrived at the hospital ED via ambulance.

Upon arrival to the facility the surveyor met with Employee Identifier (EI) # 1, Director of Quality/Compliance who provided the facility self-report documentation and the Plan of Action (POA) developed and implemented on 9/10/18:

The POA included the following Immediate Action Items:

a. Investigate Incident, interview staff, meet with PCAS (Pickens County Ambulance Service) Director - completion date 9/10/18.

b. Review EMTALA P & P (policy and procedure) and rules with ED staff - completion date 9/14/18.

c. Add EMTALA review to Department Orientation - completion date 9/11/18.

d. Add EMTALA P & P review to General Orientation - completion date 9/11/18.

e. Establish protocol for notifying EMS/Ambulance service when equipment out of order that causes diversion - completion date 9/11/18.

Refer to 2406 and 2407 for findings.

Based on facility self-reported Event Investigation and Plan of Action (POA), facility policy review, interviews with facility staff, Emergency Department (ED) physician and the local Ambulance Service Director, review of the ED registration log, review of the ambulance run report, and review of the ED record from Hospital # 2, it was determined the facility (Hospital # 1) failed to provide a Medical Screening Examination (MSE) for a patient involved in a motor vehicle accident (MVA) that arrived at the hospital ED via ambulance.

Findings include:

Policy: Statement on "EMTALA" Emergency Medical Treatment and Labor Act
Department Affected: Emergency Department
Date: 09/2013

Summary: EMTALA imposes a legal duty on a hospital to provide to any individual who presents to the emergency department and requests an examination or an examination is requested on their behalf a medical screening examination (MSE) to determine whether an Emergency Medical Condition (EMC) exists; and if an EMC exists, any necessary stabilizing treatment must be provided to an individual for whom a prudent layperson would believe he/she would desire or require such treatment.

Potential Patients: EMTALA applies to:
...Any individual who comes to the Emergency Department (see below) and a prudent layperson would believe based on the individual's appearance or behavior, that the individual needs treatment for an emergency medical condition.

"Comes to the Emergency Room": Anyone on hospital property is deemed to have "come to the Emergency Room."

Medical Screening Examination (MSE): PCMC must provide a Medical Screening Examination to any individual to which the obligation of EMTALA apply...

Review of the facility documentation submitted 9/12/18 by Employee Identifier (EI) # 1, Director of Quality/Compliance, to Centers for Medicare & Medicaid Services (CMS) revealed a 69 year old patient (Unsampled Patient # 1) involved in an MVA on 9/9/18 was brought to the facility ED (Hospital # 1) via ambulance at approximately 5:00 PM. The facility CT (Computerized Tomography) scanner was not working and the ambulance service was advised to take the patient to the closest facility with a CT scanner. The response was "we are bringing him/her there (Hospital #1). The ambulance arrived at Hospital #1 approximately 3-5 minutes later. The ED nurse went out to the ambulance bay and had a discussion with the patient's (spouse) and the decision was made to transport the patient to Hospital # 2.

Review of the ED registration log dated 4/1/18 through 9/12/18 revealed no record of Unsampled Patient # 1 on the ED log.

A phone interview was conducted on 9/14/18 at 8:25 AM with EI # 2, Registered Nurse ED, Date of Hire 5/14/18.

EI # 2 verified she was working in the ED on 9/9/18 and remembered the event involving Unsampled Patient # 1. EI # 2 stated the ambulance called with a MVA-patient hit head - no loss of consciousness - was walking at the scene. EI # 2 stated she informed the ambulance staff the CT scanner was down and was told the patient wanted to come there (Hospital #1). EI # 2 stated she informed the doctor (EI # 3, ED Physician) and was instructed to call the ambulance back and tell them to take the patient somewhere that had a CT scanner. The ambulance arrived at the ED "by the time I got off the phone with them". EI # 2 stated she went out to talk to the patient - the ambulance door was opened and I saw him/her. He/she said "I'm fine." EI # 2 stated the patient's (spouse) wanted him/her to "get head scanned". EI # 2 verified the patient remained in the ambulance and was not examined by the physician.

A phone interview was conducted on 9/14/18 at 8:40 AM with (Ambulance Service Director), who confirmed they were notified the CT was down the first day it went down (9/8/18). She stated that usually they (Hospital # 1) get it back up and running by the next day. The Ambulance Service was not informed the CT scanner remained down until the ambulance was already on the way to the (Hospital #1). In fact, the ambulance pulled up at Hospital # 1 as the call ended.

The Ambulance Service Director further verified the hospital staff had met with her on 9/10/18 to develop a plan to avoid this happening in the future. The ambulance service will be notified on a daily basis if the scanner remains down.

A phone interview was conducted on 9/14/18 at 9:38 AM with EI # 3, ED Physician. EI # 3 verified he was working in the ED both Saturday and Sunday (9/8/18 and 9/9/18) and the CT scanner was down. EI # 3 was asked to describe the events of 9/9/18 regarding Unsampled Patient # 1. EI # 3 stated EMS (Emergency Medical Services) picked up a head trauma. The nurse informed them the CT scanner was down. EI # 3 stated "(spouse) was there and wanted (the patient) to go where he/she could get a scan". EI # 3 confirmed, "I did not actually hear the conversation". EI # 3 stated,"out of courtesy I called (Hospital # 2) and told them about the situation. I did not order a transfer". EI # 3 confirmed he did not examine the patient or provide treatment.

Review of the EMS Run Report Dispatch # 090918-4126 for Unsampled Patient # 1 revealed the following documentation:

Pat (patient) arrived dest. (destination) time: 17:11 (5:11 PM) (Hospital # 1)
Transfer care time: 17:20 (5:20 PM)

"PT REQUESTED TRANSPORT TO (Hospital # 1). EN ROUTE NURSE ADVISED THAT CT MACHINE WAS DOWN.
ADVISED PT OF THIS AND THAT HE MAY BE TRANSFERRED LATER. PT STILL WANTED TO BE TRANSPORTED TO (Hospital # 1).
UPON ARRIVAL MET NURSE AT BACK DOOR OF AMBULANCE THAT TOLD PT THAT CT WAS DOWN AND THAT HE WOULD HAVE TO HAVE ONE DONE SINCE HE HIT HIS HEAD IN THE MVA.
ADVISED TRANSPORT TO (Hospital #2). CALLED (EMS Medical Director) AND SPOKE TO DR (name) AND ADVISED OF SITUATION. TOLD... PT WANTED TO BE TRANSPORTED TO (Hospital #2) IT WAS OK WITH HIM.
ADVISED PT AND HE CONSENTED FOR TRANSPORT TO (Hospital #2) ER. CARE AND REPORT GIVEN TO RN".

Review of the ED record from Hospital # 2 revealed Unsampled Patient # 1 arrived in the ED on 9/9/18 at 6:12 PM and a MSE was conducted at 6:18 PM. Unsampled Patient # 1 was treated and discharged home 9/9/18 at 9:22 PM in stable condition.

Based on facility self-reported Event Investigation and Plan of Action (POA), facility policy review, interviews with facility staff, Emergency Department (ED) physician and the local Ambulance Service Director, review of the ED registration log, review of the ambulance run report, and review of the ED record from Hospital # 2, it was determined the facility (Hospital # 1) failed to provide stabilizing treatment for a patient involved in a motor vehicle accident (MVA) that arrived at the hospital ED via ambulance.

Findings include:

Policy: Statement on "EMTALA" Emergency Medical Treatment and Labor Act
Department Affected: Emergency Department
Date: 09/2013

Summary: EMTALA imposes a legal duty on a hospital to provide to any individual who presents to the emergency department and requests an examination or an examination is requested on their behalf a medical screening examination (MSE) to determine whether an Emergency Medical Condition (EMC) exists; and if an EMC exists, any necessary stabilizing treatment must be provided to an individual for whom a prudent layperson would believe he/she would desire or require such treatment.

Potential Patients:EMTALA applies to:
...Any individual who comes to the Emergency Department (see below) and a prudent layperson would believe based on the individual's appearance or behavior, that the individual needs treatment for an emergency medical condition.

"Comes to the Emergency Room": Anyone on hospital property is deemed to have "come to the Emergency Room."

Stabilizing Treatment: If an EMC is found to exist, the hospital must stabilize the patient before he/she is discharged or transferred, subject to the following:
Stabilizing treatment must be provided within the capabilities and resources of the hospital. If the hospital is unable to stabilize the patient, the patient should be appropriately transferred to a facility that can provide the required care...

Review of the facility documentation submitted 9/12/18 by Employee Identifier (EI) # 1, Director of Quality/Compliance, to Centers for Medicare & Medicaid Services (CMS) revealed a 69 year old patient (Unsampled Patient # 1) involved in an MVA on 9/9/18 was brought to the facility ED (Hospital # 1) via ambulance at approximately 5:00 PM. The facility CT (Computerized Tomography) scanner was not working and the ambulance service was advised to take the patient to the closest facility with a CT scanner. The response was "we are bringing him/her there (Hospital # 1)." The ambulance arrived at the facility approximately 3-5 minutes later. The ED nurse went out to the ambulance bay and had a discussion with the patient and (spouse) and the decision was made to transport the patient to Hospital # 2.

Review of the ED registration log dated 4/1/18 through 9/12/18 revealed no record of Unsampled Patient # 1 on the ED log.

A phone interview was conducted on 9/14/18 at 8:25 AM with EI # 2, Registered Nurse ED, Date of Hire 5/14/18.

EI # 2 verified she was working in the ED on 9/9/18 and remembered the event involving Unsampled Patient # 1. EI # 2 stated the ambulance called with a MVA-patient hit head - no loss of consciousness - was walking at the scene. EI # 2 stated she informed the ambulance staff the CT scanner was down and was told the patient wanted to come there (Hospital #1). EI # 2 stated she informed the doctor (EI # 3, ED Physician) and was instructed to call the ambulance back and tell them to take the patient somewhere that had a CT scanner. The ambulance arrived at the ED "by the time I got off the phone with them." EI # 2 stated she went out to talk to the patient - the ambulance door was opened and I saw him/her. He/she said "I'm fine." EI # 2 stated the patient's (spouse) wanted him/her to "get head scanned." EI # 2 verified the patient remained in the ambulance and was not examined by the physician at Hospital # 1.

A phone interview was conducted on 9/14/18 at 8:40 AM with (Ambulance Service Director), who confirmed they were notified the CT was down the first day it went down (9/8/18). She stated that usually they (Hospital # 1) get it back up and running by the next day. The Ambulance Service were not informed the CT scanner remained down past 9/8/18 until the ambulance was already en route with an MVA patient (Unsampled Patient # 1). In fact, the ambulance pulled up at the hospital as the call ended.

The Ambulance Service Director further verified the hospital staff had met with her on 9/10/18 to develop a plan to avoid this happening in the future. The ambulance service will be notified on a daily basis if the scanner remains down.

A phone interview was conducted on 9/14/18 at 9:38 AM with EI # 3, ED Physician. EI # 3 verified he was working in the ED both Saturday and Sunday 9/8/18 and 9/9/18 when the CT Scanner was down. EI # 3 was asked to describe the events of 9/9/18 regarding Unsampled Patient # 1. EI # 3 stated EMS (Emergency Medical Services) picked up a head trauma. The nurse informed them the CT scanner was down. EI # 3 stated "(spouse) was there and wanted (the patient) to go where he/she could get a scan." EI # 3 confirmed, "I did not actually hear the conversation." EI # 3 stated, "out of courtesy I called (Hospital # 2) and told them about the situation. I did not order a transfer." EI # 3 confirmed he did not examine the patient or provide any treatment.

Review of the EMS Run Report Dispatch # 090918-4126 for Unsampled Patient # 1 revealed the following documentation:

Pat (patient) arrived dest. (destination) time: 17:11 (5:11 PM) (Hospital # 1)
Transfer care time: 17:20 (5:20 PM)

"PT REQUESTED TRANSPORT TO (Hospital # 1). EN ROUTE NURSE ADVISED THAT CT MACHINE WAS DOWN.
ADVISED PT OF THIS AND THAT HE MAY BE TRANSFERRED LATER. PT STILL WANTED TO BE TRANSPORTED TO (Hospital # 1).
UPON ARRIVAL MET NURSE AT BACK DOOR OF AMBULANCE THAT TOLD PT THAT CT WAS DOWN AND THAT HE WOULD HAVE TO HAVE ONE DONE SINCE HE HIT HIS HEAD IN THE MVA.
ADVISED TRANSPORT TO (Hospital #2). CALLED (EMS Medical Director) AND SPOKE TO DR (name) AND ADVISED OF SITUATION. TOLD... PT WANTED TO BE TRANSPORTED TO (Hospital #2) IT WAS OK WITH HIM.
ADVISED PT AND HE CONSENTED FOR TRANSPORT TO (Hospital #2) ER. CARE AND REPORT GIVEN TO RN".

Review of the ED record from Hospital # 2 revealed Unsampled Patient # 1 arrived in the ED on 9/9/18 at 6:12 PM and a MSE was conducted at 6:18 PM. Unsampled Patient # 1 was treated and discharged home 9/9/18 at 9:22 PM in stable condition.